Citation Nr: 21075611 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-32 185 DATE: December 21, 2021 ORDER Entitlement to service connection for diabetes is denied. FINDING OF FACT The weight of the most probative evidence of record weighs against a finding that the Veteran's diabetes began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for diabetes due to service or service-connected disease or injury are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has active service from January 1981 to August 2003. This case is before the Board of Veterans' Appeals (Board) from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018 and May 2021, the Board remanded this claim to the RO for additional development. Finding there has been substantial compliance with the previous remand directives in accordance with Stegall v. West, 11 Vet. App. 268, 271 (1998), appellate review may proceed. Service Connection for Diabetes. The Veteran has claimed entitlement to service connection for his currently diagnosed diabetes. He contends that his diabetes began to manifest during service, as evidenced by high cholesterol noted in his service treatment records. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Secondary service connection may be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In addition, where a veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When a chronic disease manifests to a degree of 10 percent or more within 1 year from the date of separation from service, that disease is presumptively service connected. 38 C.F.R. §§ 3.303 (b), 3.307(a)(3). Diabetes is contemplated as chronic disease under 38 C.F.R. § 3.309(a). Post-service treatment records reveal regular treatment for diabetes during the appeal period (07/31/2018 CAPRI, pg. 1). As a current diagnosis is confirmed by the record, the question for the Board is whether his diabetes began during service or is otherwise related to or aggravated by an in-service injury, event, or disease. The Board notes that the Veteran is service-connected for obstructive sleep apnea, generalized anxiety with panic attacks and depressed mood, hypertension, gastroesophageal reflux disease (GERD), and allergic rhinitis (12/22/2020 Rating Decision - Codesheet). The service treatment records do not reveal treatment for diabetes during service. Although in-service high glucose readings were noted during service, the Veteran was found qualified for retirement and clinically evaluated as normal at his separation physical (04/23/2015 STR Medical, pg. 3). A number of VA opinions with regard to the Veteran's diabetes are of record. An August 2016 examiner opined the Veteran's diabetes is less likely than not (less than 50 percent) incurred in or caused by, or the same condition as, abnormal glucose readings during service. The examiner explained that the in-service analysis of the Veteran's blood glucose levels reveals some elevated glucose values. They were not however sustained on repeat determinations and did not meet the diagnostic criterion for diabetes. The examiner explained the requirements for the diagnosis of diabetes were met after the Veteran left the military. The Veteran was noted to have prediabetes in 2007 with a formal diagnosis in 2010, years after service (08/24/2016 VHA Clarification). An August 2019 VA examiner opined the Veteran's diabetes was not caused by or aggravated beyond its natural progression by primary insomnia, allergic rhinitis GERD with Nissen, obstructive sleep apnea, or hypertension. The examiner explained there is no evidence of the Veteran's diabetes being aggravated by any cause, including the service-connected disabilities, and the medical literature does not support aggravation (all opinions identified as 08/08/2019 C&P Exam) The examiner addressed the November 2017 analysis of a portable sleep study that noted evidence to suggest that untreated obstructive sleep apnea may have an adverse effect on hypertension and diabetes (11/09/2017 Medical Treatment Record - Government Facility, page 8). The August 2019 examiner explained that diabetes and sleep apnea are not medically related. Diabetes is a separate entity entirely from the service-connected sleep apnea. Per the examiner, medical literature does not support a causal medical relationship between sleep apnea and diabetes. In the Veteran's case, the examiner noted the Veteran's diabetes is more likely due to his family history and being overweight and there is no evidence his diabetes has been aggravated by any cause including sleep apnea. The examiner also opined the Veteran's diabetes was less likely than not (less than 50 percent probability) caused by the in-service high cholesterol. The examiner explained the two conditions (diabetes and high cholesterol) are medically unrelated and medical literature shows no nexus between the two conditions (08/08/2019 C&P Exam). Most recently, a September 2021 examiner provided negative nexus opinions, consistent with the August 2016 and August 2019 opinions. The September 2021 examiner explained further that the diagnosis of diabetes is not likely incurred in service or caused by hypercholesterolemia present during service. The examiner acknowledged that diabetes and hypercholesterolemia frequently co-exist, but does not mean that hypercholesterolemia leads to diabetes. The examiner concluded that the Veteran's in-service hypercholesterolemia was not a pre-diabetic condition and stated the Veteran was not a diabetic while on active duty. The examiner explained the Veteran's reports about his symptoms do not align with how diabetes is known to manifest, and the Veteran's reports generally are inconsistent with medical knowledge. The examiner considered the Veteran's assertion that during active duty he experienced episodes of hypercholesterolemia (high cholesterol), that he alleges were an indication of diabetes onset while on active duty. The examiner explained that a person does not have episodes of hypercholesterolemia. It is a chronic metabolic condition with genetic and acquired etiologies and although complex, the notion that high cholesterol causes diabetes or indicates early diabetes is not true. The September 2021 examiner also opined the Veteran's diabetes is not proximately due to or the result of obstructive sleep apnea. Specifically, with regard to the November 2017 sleep study doctor's statement that there was evidence to suggest that untreated sleep apnea may have an adverse effect on hypertension and diabetes is part of general recommendations and does not mean that sleep apnea will cause diabetes. The examiner also noted that peer reviewed medical literature does not support a relationship between sleep apnea and diabetes. The examiner specifically considered whether the Veteran's service-connected sleep apnea aggravated his diabetes beyond its natural progression. Peer reviewed medical literature does not support such a nexus and the presence of the Veteran's sleep apnea prior to its formal diagnosis did not cause or aggravate his diabetes. The examiner also included medical literature citations in the provided opinion (09/13/2021 C&P Exam). Taken together, the Board finds the medical evidence of record, most notably the September 2021 opinions, weigh against a finding that he Veteran's diabetes manifested during or to a compensable degree within one year of service or is otherwise proximately caused by any of his service connected disabilities. Collectively, the medical opinions considered the Veteran's service and medical history, and the lay contentions of the Veteran. They are also grounded in medical literature. As such the Board finds the medical evidence highly probative weighing against the Veterans claim. The Board has considered the Veteran's belief that his diabetes began to manifest during service, as evidenced by documented high cholesterol or is otherwise related to his active service or service-connected disabilities. The record does not suggest the Veteran has specialized medical knowledge, training, or is otherwise competent to provide medical diagnoses, or nexus opinions regarding his diabetes. The issue is medically complex, requiring knowledge of the interaction between multiple organ systems and interpretation of laboratory diagnostic medical testing. Finding the Veteran's beliefs as to his diabetes are outside his competence, the Board cannot assign them any probative weight. Accordingly, the Board finds the previously discussed medical evidence more probative, and to weigh against the Veteran's claim. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). As the most probative evidence of record weighs against the Veteran's claim, the claim for service connection for diabetes must be denied. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. A. Myers The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.